WHY IS THIS IMPORTANT?

This is a common emergency presentation to ENT. The patient is usually in considerable discomfort and may need to go to theatre if the foreign body does not pass spontaneously. Many cases are uncomplicated and settle with medical management alone. However there is always a risk of oesophageal perforation and mediastinitis.

WHEN TO INVOLVE THE ENT REGISTRAR

Immediately: If the patient has any signs of airway compromise

Immediately: If the patient shows a high level of pain or distress (ie impending perforation), or there are signs that an oesophageal perforation has already occurred

Immediately: Any suspicion of ingestion of a button battery (usually in children)

Soon: If the patient is well but there are clear signs and symptoms of impaction of the foreign body

WHO TO ADMIT

Any patient who has got an impacted foreign body.

If the symptoms are suggestive of an upper oesophageal obstruction, then the patient is admitted under ENT; those with symptoms in keeping with lower oesophageal obstruction are admitted under gastroenterology or general surgery.

Check first that the airway is not compromised: if the patient is not short of breath and can speak normally, you can be reasonably reassured that the airway is not immediately compromised.

Accidental foreign body ingestion tends to occur more commonly in children or adults with learning difficulties. Intentional foreign body ingestion can also occur in patients with psychiatric history or in prison inmates.

History

All batteries can cause caustic burns, ulceration and perforation within hours; button batteries are commonly swallowed by younger children as they are small and appear interesting.

Take a detailed history: what was swallowed, when, what were the immediate symptoms and how are they feeling now? Can they swallow now or are they drooling?

Timing of ingestion is important as some foreign bodies may spontaneously pass.

Batteries must be removed as soon as practical.

Bottom line: If a patient feels pain or the foreign body every time they swallow, it is probably still stuck, regardless of negative imaging.

Examination

Oropharynx – the tonsils and base of tongue are common sites for fish bones to become lodged; look carefully around all the nooks and crannies; wrap a piece of folded gauze around the tip of the tongue and ask the patient to pull it forwards and down to help you get a better view. Use a headlight and a proper Lack's tongue depressor!

Abdominal examination may demonstrate small bowel obstruction/perforation – speak to the general surgeons.

Flexible nasoendoscopy is vital to examine the pharynx and larynx for foreign bodies.

The typical patient with perforation has a good history of foreign body ingestion along with:

Severe chest and/or neck pain

Odynophagia

Aphagia or drooling

Tachycardia

Tachypnoea

Pyrexia

Sometimes surgical emphysema, torticollis or trismus

Imaging

Plain AP and lateral chest and lateral neck radiographs may aid diagnosis, however not all foreign bodies are radio-opaque. (There are lists of radio-opaque versus radio-lucent fish bones in some EDs but in our experience, you should not rely on this. Bottom line: If a patient feels pain or the foreign body every time they swallow, it is probably still stuck, regardless of negative imaging.)

IMMEDIATE AND OVERNIGHT MANAGEMENT

Various medical treatments are usually tried first, although there is not much evidence available to suggest that these are more effective than observation alone.

Glucagon can be given as a slow IV bolus of 1-2 mg to relax the lower oesophageal sphincter

Buscopan (hyoscine butylbromide) is also commonly given in 20mg IV boluses, 30 minutes apart, to a maximum of five doses, for the same effect

Some teams also prescribe a prokinetic such as erythromycin, domperidone or metoclopramide to empty the stomach

In uncomplicated cases, admit the patient overnight and give IV fluids and analgesia. Oesophagoscopy (rigid or flexible) is usually performed the following day to allow time for the obstruction to pass spontaneously, as long as there are no worrying features.

Emergency endoscopy is required if the following are present

Foreign body is sharp, long (>5cm) or superabsorbent polymer and in oesophagus

Lithium/button batteries

Signs of airway compromise

Urgent Endoscopy (within 24 hours) indicated in patients with

Evidence of near complete or complete oesophageal obstruction eg unable to swallow secretions

Oesophageal food bolus without complete obstruction

Oesophageal foreign bodies that are not sharp-pointed

Sharp- pointed objects in stomach or duodenum

Magnets within endoscopic reach

Objects >6cm in length or above the proximal duodenum

Non-urgent endoscopy

Coins in oesophagus may be observed for 12-24hours before endoscopic removal if asymptomatic

Objects within stomach >2.5cm

Disk batteries or cylindrical batteries which have passed into stomach without signs of GI injury

FURTHER MANAGEMENT

If the patient becomes unwell either following initial admission or rigid oesophagoscopy, re-assess them urgently and seek a senior opinion if necessary.

Serial X-ray imaging may be useful to ensure radio-opaque foreign bodies such as coins have passed into the stomach.

Following a rigid oeosophagoscopy, patients should be observed. Once the patient’s symptoms have settled completely, the patient can introduce water, slowly leading to a soft diet. The patient can be discharged later if well.

The patient may require follow-up in clinic or a follow-up contrast study if there is any concern over underlying pathology.